Dental rehabilitation of a child with early childhood caries using Groper's appliance.

The mainstay of pediatric dental practice is the successful esthetic rehabilitation of a preschooler with advanced carious lesions. Loss of masticatory efficiency, compromised esthesis, mispronunciation of labiodentals sounds, and development of abnormal oral habits are compromises arising due to the loss of primary anterior teeth at an early age either due to trauma or due to caries. Parental desire is the most decisive factor for the placement of an anterior esthetic appliance. This unique case report highlights the fabrication of simple, Groper's appliance in a 5-year-old child with early childhood caries.

In the pediatric dental practice, the most common lesions in the anterior teeth are due to early childhood caries. It is a unique pattern of caries in very young children due to prolonged or improper feeding habits. The infant may be fed with a nursing bottle containing a high amount of fermentable carbohydrates during sleep. The sugary liquid substrate from the bottle pools around the maxillary incisors. This retentive sugary environment is highly cariogenic. The decreased salivary secretion during sleep, tooth cleaning neglect coupled with unrestricted nocturnal breast feeding increases the risk of acquiring caries. These lesions occur beginning on the labial surface of all anteriors, and they progress rapidly as a diffuse demineralization leading to the gross destruction of all anterior primary teeth.

Loss of anterior teeth in children has a far reaching impact on the psyche of the children. When these teeth are lost, replacement, and prosthetic management is very important to restore all functions including esthetics of the child. The replacement should be such that it should not interfere with the eruption process of the underlying successor. Various esthetic options are available which include removable or fixed partial dentures.

Case Report

A 5-year-old boy reported to the Department of Pedodontics and Preventive dentistry with the chief complaint of pain in the right upper and lower back tooth region for past 1 week. The parents were more concerned about the esthetics of the child, and they wanted an anesthetic replacement of the anterior teeth. The past dental history revealed that the patient underwent extraction of maxillary central (51, 61) due to caries. Intraoral examination revealed caries in 52, 53, 54, 62, 63, 64, 71, 72, 74, 75, 81, 82, 84, 85 with abscess in relation to 54, 84. There was a gross destruction of the crown of maxillary anteriors [Figures 1–4].

Figure 1

Profile picture of the 5-year-old patient

Figure 4

Preoperative occlusion on left side

Preoperative teeth in occlusion

Preoperative occlusion on right side

Radiographic evaluation

The intraoral periapical radiographs revealed deep carious lesions in relation to 52, 53, 54, 62, 63, and 64. Pulp therapy was planned for the same followed by stainless steel crowns (SSCs) in relation to 54, 64. Root stumps in relation to 84 were extracted followed by a fixed band and loop space maintainer [Figures 5 and 6].

Figure 5

Preoperative maxillary arch

Figure 6

Preoperative mandibular arch

Groper's appliance

Composite build-ups were done in 52, 53, 62, and 63 following pulp therapy. Restorations were done with glass-ionomer cement (GIC) in all the carious teeth. 54, 64 received SSCs following pulpectomy. Various esthetic options are available for replacement of primary anteriors, but, however, the Groper's appliance was chosen. Fifty-five, 65 were chosen as abutments for the anterior space maintainer. The Primary impression was made with irreversible hydrocolloid material - Alginate (3M ESPE; Palagat plus). Dental casts were poured with Type III gypsum product - Dental stone (Kalabhai). Band adaptation was done on 55, 65. The appliance is similar to a Nance palatal arch. Light cure composite teeth were built onto the cleats[1] formed by the wire that was soldered to the Nance archwire. The teeth were placed directly on the alveolar crest without any gingival colored acrylic component extension into the labial vestibule or palate [Figures 7–9].

Figure 7

Anterior view of Groper's appliance replacing the missing 51, 52, 61

Figure 9

Postoperative mandibular arch

Postoperative maxillary arch. Groper's appliance cemented in place with bands in relation to 55, 65, composite build-ups in 53, 62, 63 following pulpectomy, stainless steel crown in relation to 54, 64 following pulpectomy

Appointment schedule

First appointment

The impression was made using irreversible hydrocolloid impression material (Plastalgin). Cast was poured using Type III gypsum product (goldstone). Using a die cutting saw [Figure 10], a groove of width 0.5 mm was made on the gingival margin of 55, 65 and band adaptation was done. The “U” shaped wire component was fabricated in the cast similar to the Nance palatal arch. It was soldered to the bands. A second wire component was soldered to the main archwire. To this assembly, light cure composite teeth were built up in relation to 51, 52, and 61. The final appliance was trimmed, polished and was ready for a try.

Figure 10

Die cutting saw that was used to make the grooves of 0.5 mm width in the cast for band adaptation in relation to 55, 65

Second appointment

The appliance was tried in the patient's mouth and occlusion was checked. The appliance was then cemented using GIC with the bands in relation to 55, 65. The patient was followed up for 3 months.

Discussion

The strongest factor for the placement of an anterior esthetic appliance is a parental desire.[1] There is no strong evidence suggesting that the early loss of the maxillary incisors will cause undesirable effects on the growth and development of the child.[1] However, considerations have to be given regarding the speech problems, masticatory inefficiency, abnormal oral habits, a unesthetic appearance, which follow the loss of anterior teeth at an early age.

Loss of primary incisors after the eruption of primary canines is not an important consideration for space loss though occasionally in a crowded dentition there may be a rearrangement of some anterior teeth.[23] Another consideration is the child's speech development following extraction of primary incisors. The sounds most frequently in error are the labiolingual sounds. This is because many sounds are made with the tongue touching the lingual side of the maxillary incisors, and inappropriate speech compensations can develop if the teeth are missing.[4]

A study by Riekman and Badrawy reported that the loss of primary anterior teeth before the age of 3 years resulted in speech problems.[5] One of the most considerable and valid reasons for replacing missing anteriors are to restore an esthetic appearance and thus promote a normal psychological development in the child. When taking all the factors into consideration, if the parents have a desire to replace their child's missing anterior teeth, their wish should not be discouraged.

This space maintainer offers several advantages in terms of esthetics, restoration of masticatory and speech efficiency, and prevention of abnormal oral habit development. The main disadvantage is the accumulation of food debris and plaque. Hence, parents have to be instructed to supervise the maintenance of proper oral hygiene in their child.

This paper has offered many considerations for a pediatric dentist when considering replacement of missing primary anterior teeth at an early age.